Prior authorization peer-to-peer review: how to prepare
A peer-to-peer review is a short call between the ordering clinician and the payer’s reviewer. Preparation is what makes it work: go in knowing the exact denial reason and the policy criteria, with the supporting documentation in front of you.
Before the call
- Know the exact denial reason. Read the denial notice and identify the specific criterion the payer says was not met.
- Have the policy open. Pull up the payer’s medical policy for the procedure so you can speak to its criteria directly.
- Assemble the documentation. Have the relevant note, imaging, labs, and conservative-care history ready to reference.
- Prepare a 60-second narrative. Summarize the clinical picture and map it to the policy criteria, so the reviewer can confirm necessity quickly.
During the call
Address the stated denial reason first, then walk the reviewer through how the documentation satisfies each criterion. Be specific and concise. If the reviewer cannot approve, ask what additional documentation would change the outcome, and confirm the next step and timeline. Praxigen can assemble a peer-to-peer prep brief that lays out the criteria and the matching documentation in one place.
Frequently asked questions
What is a prior authorization peer-to-peer review?
A short call between the ordering clinician and the payer’s medical reviewer to discuss a prior authorization, often after a denial, where the clinician explains how the case meets the payer’s criteria.
How do I prepare for a peer-to-peer review?
Know the exact denial reason, have the payer’s medical policy open, assemble the supporting documentation, and prepare a concise narrative that maps the clinical picture to each policy criterion.
What should I ask if the peer-to-peer does not approve?
Ask what specific additional documentation would change the decision, and confirm the next step and timeline for resubmission or formal appeal.
More guides
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